The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Capillary refill, color of extremity.

Pedal pulses.

ACE wrap, Velcro boot, and hanging weights.

Pin sites.

Temperature, sensation, and movement of toes.

Answer and Explanation

Correct Answer : A,B,D,E

Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.

Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.

Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.

Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.

Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.

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Correct Answer is C

Explanation

Choice A Reason

Increasing sodium intake is not recommended for patients who have passed a calcium oxalate stone. High sodium intake can increase calcium in the urine, which can contribute to the formation of new stones. Therefore, patients are often advised to limit their sodium intake to reduce the risk of stone recurrence.

Choice B Reason

Considering a move to an area with higher humidity is not a standard recommendation for preventing the recurrence of calcium oxalate stones. While climate can affect hydration levels, it is more important for the patient to focus on direct measures to stay hydrated, such as drinking more fluids.

Choice C Reason

Increasing water intake is a key recommendation for patients who have had calcium oxalate stones. Adequate hydration is essential to dilute the urine, which helps prevent the formation of new stones. Patients are often advised to drink enough water to produce at least 2.5 liters of urine per day.

Choice D Reason

Decreasing the intake of all calcium-rich foods and beverages is not generally recommended for patients with calcium oxalate stones. In fact, a moderate intake of dietary calcium can help reduce the risk of stone formation by binding with oxalate in the intestines, which prevents it from being absorbed into the urine. Patients should consult with a healthcare provider or dietitian to determine the appropriate amount of dietary calcium.

A. Check blood glucose levels prior to exercising. B. Signs and symptoms of hypoglycemia. C. Weight control is necessary for this disease. D. Decrease fiber and protein in the diet. E. Obtain eye examinations every 3 months.

Correct Answer is ["A","B","C"]

Explanation

Choice A Reason
Monitoring blood glucose levels before exercise is crucial for individuals with Type 2 diabetes. Exercise can lower blood glucose levels, and it's important to ensure they are not too low before starting, which could lead to hypoglycemia during physical activity. The patient should be taught how to check their glucose and understand their target ranges.

Choice B Reason
Recognizing the signs and symptoms of hypoglycemia is essential for all individuals with diabetes, especially those on medications that can lower blood glucose levels. Symptoms may include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Patients should know how to respond to these symptoms promptly.

Choice C Reason
Weight control through diet and exercise is a fundamental part of managing Type 2 diabetes. A BMI of 28 falls into the overweight category, and reducing weight can help improve insulin sensitivity and blood glucose control. The patient should receive guidance on healthy eating and physical activity tailored to their needs.

Choice D Reason
Decreasing fiber and protein in the diet is not recommended for individuals with Type 2 diabetes. In fact, a diet high in fiber can help control blood sugar levels, and adequate protein intake is important for overall health. Patients should be encouraged to consume a balanced diet with sufficient fiber and protein.

Choice E Reason
While regular eye examinations are important for individuals with diabetes, obtaining them every 3 months is not typically necessary unless there is an existing eye condition that requires close monitoring. Generally, an annual eye exam is recommended to check for diabetes-related eye complications.

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The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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